Donning and Doffing a Prosthetic Limb – Prosthetic Training: Episode 4

January 15, 2020 0 By Jose Scott


Hi, I’m David Lawrence and in this video I’m
going to show you how to properly put on and take off a prosthetic limb, a
process known as donning and doffing. Okay. Now we’re going to talk about
liners, suspension, and sockets. Most patients these days are going to
be given some sort of roll-on liner. There are still some suction fits out
there, but that’s becoming more rare. With a liner like this, it
rolls on to the body, um, which we’ll show you with
actual patient fitting, but you basically are going to use a
pin system like this into a socket and you’re going to create a connection.
That’s going to be an audible connection, which is really beneficial for the
patient to know that I’m in there, I’m locked in to know how deep I’m in. But the big question I often get is
how far should I be in how many clicks? How do I know where I’m at? Well, the best way to do it is to put your liner
or put a liner on your arm or on your hand, slide in and engage the
mechanism till you hear a click. As it clicks, you just keep going down one click at a
time until the device goes all the way in. Sometimes you can get two or three
times, you just got to count those. You get down to 11-12 clicks. That means you’re on the bottom. The
patient needs to know that they should, if there are 12 clicks, that
means they’re bottomed out. They probably need to have
a little more sock on. If they’ve only got about six clicks,
that means they really don’t have a, they have too many socks, and
they’re not getting in far enough. Somewhere in the range of
11, 10, 11 maybe 9, 10, 11 clicks is going to be
about right in most sockets. That gives a patient a start point to
know whether they need to add socks or not to a pin suspension system. Now with a very similar type of liner, you can add a lanyard strap. This is much more common with an above
the knee or transfemoral amputation. For the trans tibial amputation, you basically are going to have a fixed
tibia with not a lot of soft tissue around it. That’s going to lock well into the
bottom of the socket and not have to be pulled in. However, when you’re dealing with
an above the knee socket, you have a lot of more soft tissue around
a single bone tucked deeper into the soft tissue. So oftentimes what happens
if you try to push into a pin system, you get a bit of an ice cream cone effect. Pushing the residual limb up over the top. Lanyard systems work better because
what you’re going to do with the lanyard system is take this strap and run it
down through a small hole that the prosthetist will place in
the base of the socket. Once you get the lanyard into the strap,
you basically just pull it through. You can see how then you can draw the
residual limb down into the socket. Instead of it being pushed up over.
Once you pull it down through, you’re going to pull the strap up, run it through the D ring and wrap
it back over and Velcro it to itself. Now the key with these when you put them
on is you always pull the strap tension from here and then just run it
through the ring and re strap it. You don’t want to pull on this D-ring as
your lynch point because it’s very easy to pull this rivet out
or pull the D-ring apart, but that locks that individual down into
the socket so there’s no way that it can come off. Okay. The next form is a seal-in system.
This is using the same kind of gasket, the same type of liner material, but
you notice there’s no pin or lanyard, nothing that’s going to attach them to
the bottom of the socket or hang it from the base of the socket. This is going to create a system in which
you’re trying to bring the attachment point more broad all the way around
and higher up into the socket. What you do with a seal-in is you put
hand sanitizer all the way around it to get it well lubricated. Put a little bit of hand sanitizer down
into the socket as well and slide these two together while it’s still wet. You
want to be pressing all the way down in. This is a one way valve so air
will come out but can’t go back in. You can press on this valve to make sure
you’re getting all the way down in and then you give it no more than 30 seconds. 45 seconds and the Purell will dry
once it dries you are sealed in. If you’re worrying or wondering
how deep they are in the socket, you can take this valve out and check
to make sure that the residual limb is right there or filling
the base of the socket. You never want an air pocket at the
bottom and if any of these sockets, because you create a pressure, a negative pressure which creates a
almost like a hickey effect on the skin, so you put this back in place,
you’re sealed in or locked in place. Last system I want to talk about is if
you are using a non seal-in type system or if you’re just having a basic, what we call a vacuum or
elevated vacuum system. With that you’re going to need a liner.
This is basically the same type of, or sleeve I should say. Excuse me, same
type of material as made of the liner. But this is a sleeve that
goes over the socket. So in this particular case you would put
this over top of the socket and get a good seal to the socket itself. And then the liner will run up the leg. Now the key is how much and where
does the liner need to go to? Well, what you’re going to have in a socket, like this is a liner here on the inside
with socks that are going to come a certain amount of height above the socket. You want your sleeve to
come up at least, well, I like to say four fingers
higher than the top of the socks. That means there’s at least
that much area of the liner. Um, connecting excuse me the sleeve,
the sleeve connecting to your skin. If there’s not enough,
you can lose your vacuum, lose your connection and
the device can come off. So you want as much contact on
the skin as you possibly can get. So the liners fit into the socket. And we looked at the suspension
systems in various ways. It was important to get a general sense
of sockets themselves below the knee or trans tibial sockets, uh, tend to be a design in which you’re
going to bear some weight on the patellar tendon, but most as much as possible in total
contact or pressure all the way around the residual limb. Remember, you have a
fairly bony structure below the knee, which means there’s not
a lot of soft tissue, so the socket’s going to have to be
developed to create reliefs in the right area so we don’t get too much
pressure like on the fibular head. Um, and there’s enough room for you to slide
down into the socket completely. Um, there can be different
types of ways to suspend it, but most of your systems are going to
involve some sort of level of either suspension right at the knee or they can
bring the socket up a little bit higher than the, to get a little bit more suspension
around it based on the prosthetist you’re working with and your individual needs. When you’re talking
above the knee sockets, this is probably your most
common socket design now. Well they called your narrow ML
or ischial containment socket. This is the type of socket in which
your ischial tuberosity or your sit bone should sit right here on a
shelf inside the socket, right? So it has a place for it to sit right
here or be cupped is probably the best word and you’ve locked them ischial-wise
into the socket that distributes force all the way down through the socket.
But there’s a bony landmark on the top. Now there are older sockets, um, which are a quadrilateral socket where
there’s actually a seat for the ischial tuberosity so you don’t have to sit
down into it and very modern or more new sockets out there. The Moss socket is one that
has a different form of
suspension all the way to the top or support for
the skeletal structure. And then the issue is now you hear a
lot with what’s called brimless sockets. Where you have elevated vacuum to hold
the patient into the socket and there’s no brim whatsoever. What’s
the benefit of that? The benefit is that when you sit,
uh, there’s nothing to sit on. There’s no socket back
here to be uncomfortable, so you have a lot less
pressure in that area. The negative is trying to get a suspension
that if you’re going to be an active individual, the prosthetics not
going to rotate on your spin. or stay consistently bearing load. If
you can have the ischial containment, you actually get a better distribution
of load directly to the skeletal system, not going through soft tissue, which is the way you’re designed on the
sound side of having a bone structure to the ground. Alright now we’re going to be talking
about fitting the below the knee or trans tibial amputation and with a trans
tibial or below the knee socket. In this particular system,
we’re going to use a liner, a system with a sleeve
over the top of a socket. So to get started, what you want to do is roll
this liner all the way out, alright? So there’s no wrinkles
and no gap here at the bottom. Really important on these issues as
well as the hygiene of these liners. You want to clean them every day. It is very easy to get a
contact dermatitis from these
and you want to clean the inside. Don’t get the outside wet. If you get this nylon material wet, it’ll
smell and it will stay pretty smelly. So if you wash it right in the
sink, like I’m holding it now, let it rinse off completely
mild soap, no deodorant, no um, smells or perfumes or
anything like that. Lemon fresh, just the most simple of
soaps turned inside out, hanging on a stand or lay it out, but don’t ever lay it down with this
inside material touching anything that it touches. Cat hair, dog hair,
a newsprint of a newspaper. Everything will be picked up. And then that will be a
problem with putting it into
the limb when you put it on or push it into your skin. So you
turn this all the way inside out. Make sure that there’s no air gap. You’re going to put it right on
the end of the residual limb use… Notice I’m using the flats in my hands, not grabbing with my fingertips and I’m
just sliding my hands towards her As I do that, the the device or the sleeve
basically wants to pull itself on. This one has some wear, so it’s
going to roll on easier. A new one, you have to put a little bit more effort
in to get it to roll all the way up. At that point in time, you just want to make sure there’s no
wrinkles and no air pockets from top to bottom, and the thicker side of the liner should
always be in the top and the thin on the backside. That means it’ll bend
easier without pinching behind the knee. If the patient needs socks. And
in Carol’s case we need that, so we’re going to put a sock
over the top. With socks, it’s important to realize these are
Lycra based, so this is a three ply sock. If you yank it hard enough, you
can turn it into a one ply sock. So you want to keep it a full three
ply sock by pulling the wrinkles out, but not stretching or yanking on it. That way it gets the sleeve solid with
a sock over top of it with no wrinkles. The next issue becomes the sleeve
over top. This is the liner, the sock, and now the sleeve. With the sleeve, what we want to do is we want to put it
into a position where it has plenty of contact on the socket. That means it’s well-connected on the
socket and plenty of material to maintain position and create that
vacuum or seal to the skin. You roll the outside down
and when you roll it down, you always want to roll it down past
the back wall of the prosthetic socket. If not, that will pinch or catch on the
way on and then you may lose suspension. Or be just very uncomfortable as well. From this point when you take our socket
and simply slide it into place with the knee cap sitting right in
the center of the groove. So bend your knee a little
bit, Carol. There you go. And that knee cap should sit in the middle
though I don’t want to put that on on an angle in any way that’s going to be
uncomfortable directly in the center of the groove. Now with a new patient with
a lot more soft tissue or more swelling, you have to take your time a little bit
to work the socket into place because it will hold and maybe hang up somewhat.
Once she’s in there in that position, you’re basically wanting to do the same
idea of the flats of your hands to to slide the the liner up
onto the residual limb. Now, here we have a little bit of the liner
underneath catching and what can help that is ask your prosthetist to put a
little bit of prosthetic tape right around the top by base of the liner to hold it
down and then it won’t adhere or stick to the liner as you’re rolling
it up. So we get this position, we roll it right to the top. Now you’ll notice here that I stopped
rolling it up right at the top of her um, liner internally. So as
I pull this sleeve up, I want to make sure when I get to that
point I have about again four fingers of width for this liner to make good
contact or sleeve, excuse me, good contact with the skin. So at that point I’m just going to roll
that up and make good contact with the skin and bring it all the way up. Now at this point in time you notice that
there’s no wrinkles all the way down. Yeah. And tension wise that is locked onto her
residual limb and all the way down and she can bend it right into position,
but that gives it a good stable base. Right now we’re fitting the below-knee
amputee or trans tibial amputation with a silicone suspension system and a pin. That means we have a roll on sleeve
that has a pin that engages audibly down into the bottom of the socket. This is helpful for patients
to know how deep they are. They can count the clicks and determine
the depth they are down into the socket. With a system like this,
much like any other, uh, liner suspension, you want
to roll it inside out. You always want to keep this very
clean, top to bottom, uh, and make sure, again, when you clean
it, you don’t get the uh, nylon side wet or it will smell
usually come in here and grab the pin, hold that under the water and you can
rinse it really good inside out to dry it. Don’t ever lay it down like this. If
you’re going to lay it down anywhere, roll it back, right side
out. At this point in time, our key is that we have to have
the pin become an extension of her, the bone of her leg. So if you put that on in a position
too low and you start to roll up, you’re going to see that pin is not facing
directly out from the end of her leg it is not going to engage well in
the housing. This sounds simple, but it’s a difficult thing for
patients to always get that pin right. So what you’re going to do is put that
and try and get that pin as a direct extension of the bottom of the leg. And
again, using the flats of the hands, not the fingertips, just slide
that liner all the way up. If we have a good position, we have the pin coming directly
off of the end of the limb. Before you put any socks on is a good
time to check and see if you generally have it right. If you do, you can hear
those clicks. It is clicked into place. That means we do have the
sleeve in the right position. Once you put the socks on that she
normally needs to be able to walk. It’s going to be harder
to get it to engage. So a good way to check your
alignment is just slide it on first. She uses a five ply sock. Remember with
our socks, they can come in one, three, five, two ply, whatever. This basically stands
for five one ply sock. So it is a thicker sock that
has a hole in the bottom. Now why is that important? Because if you put this prosthetic on
with the pin pulling through the sock like this, it will sometimes go down in and engage
but it will not come off at that point. You become locked into the socket. You have to contact the prosthetist to
have the prosthetic device taken apart from underneath to get out of the socket. So it’s really important to make sure
that if you put a sock on over top of a pin suspension that the pin clearly and
completely is free from the bottom of the pin. Now in an absolute difficult situation
where you can’t get to that prosthetic limb maker, what you can do, and it is possible that if you can take
warm water and pour enough warm water down inside this liner and
you get enough water in there, you can slide it off. It’s like being
extremely sweaty all the way around. It takes a lot of water, a lot of patience and a lot of time
so that way you can get it off without having to get the pin
disengaged from the socket. But to never make that
mistake is the best way. And to make sure you always
have the patient come down, put their hand down and just check to
make sure they feel that pin is completely free from the sock, nothing to
get caught up in the housing. From there, we don’t have any
external sleeve at this point in time. All the suspension is going to
come from within the socket, so in this position we’re here, kneecap should be in the center
of the horseshoe in the front. Relax that knee a little bit. Most patients want to stiffen the knee
up and become real stiff and tight and that causes the leg to expand and then
it becomes a bit of a Chinese finger torture. The harder you press,
the more does not want to engage, but if you can get them to
relax that leg a little bit, let it bend a little bit, then we can get it down and you can
hear that engagement that’s starting to click in there is a click.
So now she’s engaged. One click means that’s not
coming off. You can pull, it’s not coming off and the rest of it
can come from pressing in or when she stands up to click in the rest of the way, so here we let that
knee bend a little bit, try to be relaxed and give a little
more press to get down into the socket. If she’s doing that herself,
she’s going to bend her knee. She can put her hands and go ahead and
do it Carol, as far as pressing down in, there we go. So then that’s down in and clicked
into position and she’s locked in. If she got up and started walking around, this leg would click in a click or two
deeper and that would be at the base it’s a fairly short pin system. Now the big key then is she is locked in. How does she get out of it at that
point in time on the inside wall there’s going to be a button. Sometimes there’s a cosmetic cover
where you have to feel for that opening, but on this one you can see the opening. All Carol has to do is press on that
button and lift her leg up and the pin comes directly out. All right, a hybrid system that’s available is a
system in which you use a pin suspension on a sleeve and you combine that with a
system that allows you to ratchet down and tighten up the socket all the way
around from both sides and from the back. So, um, how this works is you’re going to put
this guy on bend the knee there for me, Percy. There you go. And we’re going to slide in till you
hear the clicking that’s engaging that prosthetic down in. However, one
of the additional components here, which is nice, is the individual then can engage this
strap and tighten up these windows to adjust the fit based on more or less
swelling and getting the fit right where they want it for that
particular given time. When we’re fitting the above the knee
or transfemoral patient with a lanyard system that’s basically a liner that has
a strap that’s a Velcro based lanyard strap that will attach and hold
suspension from below the socket. So how you put this on,
you’ll notice that the, the prosthetist has cut it lower
on the inside than the outside. That should be the groin side. You want to turn the liner completely
inside out and completely flush at the bottom. Remember there can be no
air pocket here at the bottom. If you put this on with an air pocket,
you create a hickey effect at the bottom. You can create a lot of skin damage, so you always want to flush it all the
way out either if the therapist is doing this or the patient, you make
sure that that lower side, it’s cut up higher I should
say is on the inside. Stick this right on the end of the
residual limb, flush to it, and again, roll it up. What you’re looking for
is simply keeping your hands flush. Don’t grab it with your fingernails.
You can cut holes in the liner. Just kind of use the flat of
your hand to slide it up the leg. It’s going to want to work its
way up there. When they’re new, they’re a little bit stiffer and
don’t roll it quite as easily. But once we get up at
about this far, Percy, go ahead and help me out and pull
that guy all the way up around. There you go and you have to kind of
lift up to get it to clear the base and then pull the shorts out so that you’re
not got everything caught up in the socket. Here we go and
bring it around the front. Now we’ve got our lanyard strap. We
want to unhook that lanyard strap. We’re going to take our prosthesis at
this point in time and you’ll notice in this prosthetic we have socks. That means if the patient has
got a fit that needs a sock, you need a particular sock that has
a hole built into the bottom of it. What you’re going to do is take that sock, put your lanyard strap through
it here and pull it up flush. Percy. If you’ll grab him, pull
that sock up flush, that’d be great. And we get that level and you pull it all
the way to the top cause you want your socks to come up over
the brim of the socket. That also keeps some of the plastic from
rubbing on your skin and also keeps any wrinkles out of the socket or
the liner. From that point, the lanyard strap goes down through a
hole that the prosthetist has cut in the bottom of the socket. Again, you
do this yourself as a patient. You’re looking down through and pulling
the leg through that or the lanyard through that hole. You’re going to pull that leg up
as best you can into position. That doesn’t have to be
on perfectly, just close, and so you get to a position where
you pull up the best you can, give it a little tug down
and at this point in time, that thing is not on all
the way, but it is on solid. You could really drag someone across the
clinic floor with it in this position. You don’t need to do that. Now what you’re going to do is bring
up the a walker in a position here, so the patient’s in a stable position. I’m going to let you Percy go ahead
and stand up. When you’re ready. There you go. And lean
forward into it. Beautiful. From that position he just brings the
prosthetic back and settles his weight down into it. I’m going to adjust and he can do
the same with just socks and liner, pull the shorts out a little bit, but you’ll notice what’s happening here
is this lanyard strap will start to become a little bit loose, so you grabbed that lanyard strap and
give it a bit of a tug down and that pulls you in a little bit tighter. Notice
when you pull on the lanyard strap, you pull from the bottom of the
strap. You don’t pull from the D ring. This ring up on the top cause
you’ll pull the rivet right off it. You always pull from the bottom, come
through the D ring and take up the slack. Now that makes a good
solid fit. Now Percy, show them how you would do that
yourself. If you adjust that strap. There you go right there. Just showing
them how it’s done. There you go. Here you go. Notice how he’s balancing with one
hand using one hand to pull it through, taken up the slack and he’s got
a good solid fit. From there, the shorts come out and
he’s in a stable position. All right what we’re doing here
is fitting the above knee socket, um, with a seal-in system. That’s a system that has a roll on
sleeve and a gasket built into it. The gasket will seal to the prosthetic
socket and that gives us our suspension. There is no need for a strap
or pin in this type of system. When you’re donning the liner, it’s really important that you turn that
liner all the way inside out to start with and you’re not going to
come down and leave any space. You want to pull it all the way inside
out until it flattens out completely. At the second point you’re going to
look and see that it’s been cut by the prosthetist lower on one
side than on the other. So you want to make sure that is
going to go into the groin side. So you flush this out completely. You’re going to put that right on
the and break it down a little bit, right on the end of the residual limb and
basically as you come up it’s going to want to drag itself or pull itself up
the leg and that’s all you’re doing is you’re pulling that and sliding up.
To the patient, it’s the same way, you notice I’m not using my
fingertips and yanking on it. I’m basically just using the flat
of my hand and letting it roll up. Very large shorts are helpful in this
area so that you have room to work and we’ll pull it all the way up. So Percy, if you want to go ahead and help me
pull that all the way up into place. A lot of times with the chair you have
to kind of lift up a little bit to get the base all the way underneath
and bring it all the way around. Go and bring your leg all the way down. There we go and we flush
it all the way out. That way we know the socket’s going to
sit right in the right position. Perfect. Now the gasket here can turn inside
out. And if the patient needs (socks), you need special socks, these
are socks with a wide open end. And what you’re going
to do with this sock, let’s put it over top of the liner. Come above the gasket here, but pull the base of the sock right down
to the liner or the gasket and pull it over top. This holds the sock down in place and
then we would roll the sock all the way up flush before putting the prosthetic
on. In this particular case, the patient doesn’t need this,
so I’m going to take it off, but just showing you how that works and
we’ll take this off and set it aside. Now when the gasket is in place, it’s lying flush and
flat in this direction. And what you need is some sort of uh, sanitary moisturizing stuff, a Purell or whatever the version you
need or have is fine and you want to get the gasket fully damp. Alright, any excess on your hand, you want to go ahead and wipe in the
socket so that it will slide down in. If not, it’s going in here. Then
you have a fairly time-sensitive. You want to go ahead and get the socket
into place and begin to slide it. Don’t stand up. We’re just going to slide it into place
the best we can to begin to get that pressure down in there. Excellent. And when we’ve got it in that far and
that’s far enough to get a basic seal, you can bring a walker around whatever
the patient needs and go ahead and stand up for me. Percy comes right
down into it. There you go. And loads it, puts the pressure right
down on it. Now it’s a one way valve. That means it’s going to start
expelling air immediately. But if you press on that valve, you’ll also get more pressure
and more air coming out. So what patient does is go ahead,
show him what you do, Percy, you put the pressure on the sock…
There, you go on the socket, press on it and press down into it and
you’ll literally hear the air coming out of it and you want to do that. You want to evacuate all the air out
of the base of the socket until the residual limb is sitting flush down
into the base of the socket. Many times, once he does this a little bit,
he may have to walk a few steps, get around and then try that again until
it settles all the way down in tight so he’s got a very snug fit and that’s
what you want to have a good solid fit moving forward. From there, you just make sure shorts are pulled
out from the socket because they hit on many times we’ll hang up and give him
room to be in a good stable position. Thanks for watching and we hope that
you found this information helpful. This video is part of a series on
prosthetic rehabilitation ranging from managing the residual
limb after amputation and
progressing to running with a prosthesis. We encourage you to view our other videos
in this series and to share them as well. You can find them on our YouTube
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